DIGITAL SUBTRACTION ANGIOGRAPHY (1)

Introduction

Digital Subtraction Angiography (DSA) refers to the acquisition of digital fluoroscopic images
combined with injection of Contrast Media and real-time subtraction of pre- and post-contrast
images to perform angiography. It is used in interventional radiology to visualize blood vessels
in a bony or dense soft tissue environment. The images are generated using contrast medium and
subtraction of a "pre-contrast image" or mask from subsequent images, once the contrast medium
has been introduced into a structure.

History

In 1927, Egas Moniz developed the technique of contrast Xray cerebral angiography. This was
used to diagnose diseases such as tumors and arteriovenous malformations. In 1935 conventional
subtraction imaging was proposed by Dutch radiologist Ziedses des Plantes. He could produce
subtracted images using plain films under 3 conditions: a scout film, angiographic film (contrast)
and the subtracted. The scout film shows the structural detail of the skull and adjacent soft tissue.
Angiogram film shows exactly the same and atomic details if the patient does not move, plus the
other opacified blood vessels. If all the information in the scout film could be subtracted from the
angiogram film only the opacified vessel pattern would remain visible. In 1953 introduction of
the Seldinger technique made the procedure safer since no sharp devices needed to remain in the
vascular lumen.

The development of DSA was a result of the research of medical physics groups at the
University of Wisconsin, the University of Arizona, and the Kinderklinik in Kiel, West Germany
during the early 1970s. During the 1970s the low-osmolar contrast media (LOCM) was also
developed and helped to reduce the side effects of high-osmolar contrast medium (HOCM)
which was initially used in the procedure.

By 1978, the feasibility of DSA for human subjects was demonstrated, and prototype
commercial DSA systems were introduced in 1980 at the Universities of Arizona and Wisconsin,
the Cleveland Clinic, and South Bay Hospital in Redondo Beach, California. In the 1980s it was
the development of rapid digital subtraction techniques and rapid digital angiography that greatly
facilitated the development of the new sub-specialty of interventional radiology.

In March of 1990 W.D. Jeans from Bristol reviewed the development and use of digital
subtraction arteriography (DSA). Both intravenous and intra-arterial techniques were examined,
the intravenous techniques, however, proved disappointing. Diagnostic angiography has now
been largely replaced by MRA, CT angiography and ultrasound and DSA is commonly used as
part of an interventional procedure.

After the beginning of the 1990s, fluoroscopically guided interventional procedures have been
increasingly used to treat various neurovascular diseases. A combination of the improvement of
digital subtraction angiography (DSA) and the introduction of new devices including
microcatheters and fine guidewires as well as coils and embolic materials facilitates the
interventional treatment.

Image Formation

DSA is the computer-assisted radiographic visualization of the carotids and cerebral vessels with
a minimal view of background tissues. An image is taken before and after the injection of a
contrast medium. The first picture is “subtracted” from the second, a process that creates a
highlight of the vessels. DSA is used to assess aneurysm, arteriovenous malformations, fistula,
occlusion, or stenosis. It is considered the “gold standard” in assessment for carotid stenosis;
however, it is less cost efficient and carries a small but significant risk of stroke or death due to
the invasive nature of the test compared with MRA or carotid ultrasound. It is also used in the
operating room (i.e., television display) to examine the integrity of anastomoses or
cerebrovascular repairs.

1|Page
In DSA, the initial image from an angiographic sequence is stored in memory. The subsequent
images are subtracted from this image and displayed as a continuous display on a video monitor.
This enables a complete monitoring of the examination as it is in progress. The image
information is also simultaneously stored on a digital disk (or on PACS) at real-time rates.

Advances in digital technology, including DSA, have made it possible to acquire serial images at
rates and quantities not possible with conventional film-changer and film-cassette technologies.
Dose rates from digital imaging can be much greater than those from fluoroscopy (see the next
Entrance skin dose measurements with a phantom).

Iodine based contrast agent is injected to absorb more photons (than blood and tissue), and
increase the visibility of blood vessels.

• This is administered via a catheter under fluoroscopic conditions.

• The image is presented on a television screen formed by dots.
• Dots are aligned in rows of 512 horizontally and 512 vertically.
• The 262,144 dots constitute a picture that can be converted from continuous analogue
electrical current to pulses of electricity.
• These electrical pulses form discrete binary digital information (numbers)
• The electrical television signal is digitized and each dot is converted into a number
containing x and y coordinates for position and a z coordinate to indicate grey-scale
intensity.
• Which is how black, white, or grey each dot should be.
• The number is placed into the computer’s memory

The objective of DSA is to produce images of contrast-filled vessels in isolation from other
tissues. This provides improved clarity in the image of the vessels and permits the use of a lower
dose of contrast medium. Images of the same region are taken before and after injection of the
contrast medium. Between imaging sequences, it is important to avoid any movement of the
patient or equipment, and therefore in general the images should be acquired in rapid succession.

2|Page
DSA Equipment and Accessories

DSA requires more complex equipment than digital radiography.

Generator and Tube: The same nature of the angiographic tube and generator, without further
modification.

Image Intensifier: The digital images are taken from the television image produced during
fluoroscopy. There must also be a high contrast ratio so that small variations in beam attenuation
can be registered and used in the subtraction process.

TV Camera: A camera focuses on the images intensification image and scans it electronically.
The amount and quality of light reaching the TV camera are carefully controlled by a light
diaphragm.

3|Page
Image storage and processor: This is the section of the computer that takes the acquired images,
manipulates the subtraction, and then recreates an analog video image for visualization on a
screen.

Image Digitizer: This turns the analog TV image into a digital image consisting of pixels the
number of which depends on the lines per inch of the TV image. The usual pixel numbers in an
image are 512 X 512 or 1024 X 1024 (high resolution).

Post processing image manipulation: This is performed using the computer and images stored
within it and are performed after completion of an examination to create the best possible image.

Multi-format Camera: A hard copy of the resultant analog image can be produced using this
image processor.

4|Page
Sterile Equipment Needed:

• Sterile gowns and gloves for scrub techs and doctors.

• Sterile towels and drapes for procedure equipment covers.

• Gauze, scalpel, needles, scissors and hemostats.

• Syringe for heparin/saline flush, lidocaine, and blood draw.
• Labels with marking pen filled for any item filled with solution.
• Basin for heparin/saline mixture, basin for waste fluids, small cup for lidocaine, skin prep
solution, high power manifold-connection tubing.

5|Page
• Catheters, wires and sheaths.

6|Page